32 - Micturition

Question 1

Where is the micturation centre and what is it’s function

Answer 1

Back of the neck (pons)

Ask if socially acceptable

Question 2

What is the sensory feedback in micturition, What nerve?

Answer 2

Bladder to MC via stretch receptors

S2,3,4 branch of pelvic nerve

Question 3

Somatic to sphincter pathway and nerve?

Answer 3

Micturition centre to external sphincter
Via somatic nerves
Pudendal nerve = S2,3,4
Relaxes external sphincter to open
Sympathetic inhibited (hypogastric nerve)

Question 4

Parasympathetic to detrusor

Answer 4

Feedback loop and parasympathetic supply to detrusor muscle
Contracts
Pelvic nerves S2,3,4

Question 5

How much does a normal adult micturate

Answer 5

4 times/24 hours

1.5L

Question 6

What stimulates bladder contraction

Answer 6

Ach released from nerve endings and that stimulates muscarinic receptors on the detrusor smooth muscle

Question 7

What drug for overactive bladder

Answer 7

Anti-muscarinic drugs

Question 8

Side effects of anti-muscarinic drugs

Answer 8

Dry mouth

Question 9

Storage symptoms of LUTI

Answer 9

Frequency, nocturia, urgency, urge incontinence

Question 10

Voiding symptoms of LUTI

Answer 10

Hesitancy, poor flow, incomplete emptying, terminal dribbling, haematuria

Question 11

Overactive bladder syndrome

Answer 11

Urgency, with or without incontinence, usually with increased frequency and nocturia

Question 12

Diagnosing BPH

Answer 12

International prostate symptom score (I-PSS)

Question 13

What is the IPSS

Answer 13

Questions about symptoms

Question 14

Mild I-PSS

Answer 14

(I-PSS)

Reassure, watch and wait, reassess

Question 15

Moderate I-PSS

Answer 15

(8-19)

Question 16

Severe IPSS

Answer 16

20-35

Question 17

Low vs high QoL score

Answer 17

Low - watch and wait

High - Lifestyle and education, medication, surgery

Question 18

Investigations for urinary issues

Answer 18

Urine sample, uroflowmetry and post void residual volume

Urodynamics (pressure/flow studies) - flow decreases with age

Question 19

Obstruction disorders

Answer 19

BPH, Lithiasis, strictures, cancer

Question 20

Incontinence disorders

Answer 20

Stress, urge, mixed urinary incontinence

Question 21

Functional disorders

Answer 21

Stroke, spinal cord injury, neurological disease

Question 22

Medical disorders

Answer 22

Cardiac, hepatic and renal failure

Question 23

What is BPH

Answer 23

Prostate gland enlarges
Thickened bladder that can fail
End-fill over activity (generating large amounts of pressure and small flow)

Question 24

Conservative treatments for BPH

Answer 24

Fluid type, amount, food, smoking
Don’t drink to little (can irritate bladder)
Voiding diary

Question 25

Caffeine effect on bladder

Answer 25

Caffeine releases calcium stores from the golgi apparatus in the bladder wall, making bladder contraction more likely

Question 26

What is a bladder drill

Answer 26

Store for 3-4 hours then pee

Question 27

Medical therapy for BPH

Answer 27

- A blockers: Stretchers for smaller prostates - 5-a reductase inhibitors : shrinkers (bigger prostates) - PDE5 inhibitors

Question 28

What surgery options for BPH

Answer 28

TURP HoLEP/greenlight UroLift

Question 29

What is TURP

Answer 29

The gold standard, electric loop carves out prostate chips | - ED issues

Question 30

HoLEP/greenlight

Answer 30

Modern laser operation, better at tissue removal | - No ED

Question 31

UroLift

Answer 31

Staples prostate

Question 32

What is stress urinary incontinence and how do you treat

Answer 32

Increased abdomen pressure leaking on effort or exertion - Surgery

Question 33

Urge UI

Answer 33

Leakage and urgency | - Treat with medication

Question 34

Anticholinergics

Answer 34

Oxybutynin Solifenacin Tolterodine Fesoterodine

Question 35

MoA of anticholinergics

Answer 35

Block ACH in parasympathetic nerves | blocks elsewhere too like salivary gland

Question 36

B3 Adrenergics MoA + SE

Answer 36

Activates receptors on the detrusor to relax - Upregulated int OAB - Hypertension

Question 37

B3 adrenergic drug

Answer 37

Mirabegron

Question 38

Botulinum Toxin A MoA

Answer 38

Fuses synaptic vesicles with the motor end plate | - Used for over active bladder

Question 39

lesion above the pontine micturation centre?

Answer 39

Safe | CVA, Parkinsons MS

Question 40

Lesion below T-12

Answer 40

Safe as bladder and sphincter are flaccid + low pressure (trauma, tumours,spina bifida)

Question 41

Lesions between pontine mucturation centre => T12

Answer 41

Unsafe uncoordinated + so high pressures in the resting bladder result (RTA, Tumours, MS)